Yale Improving the Care of Persons with Complex Health Needs

Grant Summary

Under the new Developing and Disseminating Models of Care portfolio, the Hartford Foundation Board approved a $497,734 planning grant over 18 months to Yale University, with another $400,000 in related funding from other stakeholders, to develop a feasible, sustainable, model of primary care that supports a patient-centered approach to the care of older adults with complex chronic conditions. The model will then potentially be evaluated in a second phase of the initiative. Older adults, on average, see seven physicians (two primary care physicians and five specialists) a year in four different practices, often without true coordination of care. Aligning primary care and specialty care around a patient’s own health goals represents a significant opportunity to improve outcomes for chronically ill older adults. The effort will be led by Mary Tinetti, MD, director of the Hartford Center of Excellence in Geriatric Medicine at Yale, and co-led by Caroline Blaum, MD, chief of geriatrics at New York University. The initiative will build stakeholder engagement and demand for the effort by bringing together providers, payers, patients, and families to identify problems that influence quality, health outcomes, and health care costs for complex older adults and then determine the approach and corresponding evaluation plan aimed at improving care through primary/specialty and patient-centered care redesign.